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8. Foot and Ankle MCQs

Practice Set 58 of 353

This practice set contains high-yield board review questions covering key concepts in 8. Foot and Ankle. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 1141

Topic: Forefoot

What is the optimal position for a first metatarsophalangeal (MTP) joint arthrodesis to ensure normal gait and function in a patient with severe hallux rigidus?

. 0 degrees of dorsiflexion, 0 degrees of valgus, and neutral rotation
. 10 to 15 degrees of dorsiflexion relative to the floor, 10 to 15 degrees of valgus, and neutral rotation
. 30 degrees of dorsiflexion relative to the floor, 5 degrees of valgus, and neutral rotation
. 15 degrees of plantarflexion, 15 degrees of valgus, and neutral rotation
. 5 degrees of dorsiflexion relative to the floor, 20 degrees of valgus, and neutral rotation

Correct Answer & Explanation

. 10 to 15 degrees of dorsiflexion relative to the floor, 10 to 15 degrees of valgus, and neutral rotation

Explanation

The optimal position for 1st MTP arthrodesis is 10-15 degrees of dorsiflexion relative to the floor, 10-15 degrees of valgus, and neutral rotation. This position allows for adequate toe clearance during the swing phase and normal toe-off during gait.

Question 1142

Topic: Forefoot

A 58-year-old female presents with severe pain in her left great toe. Examination reveals pain specifically during the mid-range of passive dorsiflexion and plantarflexion of the 1st MTP joint. Radiographs demonstrate severe joint space narrowing and large dorsal, medial, and lateral osteophytes. According to the Coughlin and Shurnas classification, what is the most appropriate surgical treatment?

. Dorsal cheilectomy
. Moberg osteotomy
. First MTP arthrodesis
. First MTP joint arthroscopy
. Resection arthroplasty (Keller procedure)

Correct Answer & Explanation

. First MTP arthrodesis

Explanation

The patient has Grade 4 hallux rigidus, characterized by pain in the mid-range of motion and extensive degenerative changes. First MTP arthrodesis is the gold standard surgical treatment to predictably relieve pain for Grade 4 disease.

Question 1143

Topic: Forefoot

A patient undergoes a dorsal cheilectomy for Grade 2 hallux rigidus. Postoperatively, she complains of numbness along the dorsomedial aspect of her hallux. Which nerve was most likely injured during the surgical approach?

. Deep peroneal nerve
. Sural nerve
. Dorsomedial cutaneous nerve
. Proper plantar digital nerve
. Saphenous nerve

Correct Answer & Explanation

. Dorsomedial cutaneous nerve

Explanation

The dorsomedial cutaneous nerve (a branch of the superficial peroneal nerve) crosses the 1st MTP joint dorsomedially. It is at high risk of iatrogenic injury during dorsal surgical approaches for a cheilectomy.

Question 1144

Topic: 8. Foot and Ankle

In the treatment of hallux rigidus, a Moberg osteotomy is primarily designed to achieve which of the following biomechanical outcomes?

. Plantarflex the first metatarsal head to increase windlass effect
. Shorten the first metatarsal to decompress the MTP joint
. Shift the available arc of MTP motion into more dorsiflexion
. Arthrodese the MTP joint while preserving IP joint motion
. Correct concurrent hallux valgus deformity

Correct Answer & Explanation

. Shift the available arc of MTP motion into more dorsiflexion

Explanation

The Moberg procedure is a dorsal closing-wedge osteotomy of the base of the proximal phalanx. It does not increase the total arc of motion but shifts the existing restricted motion into greater dorsiflexion to improve ground clearance during gait.

Question 1145

Topic: 8. Foot and Ankle

A 65-year-old male with end-stage Hallux Rigidus (Coughlin and Shurnas Grade 4) is undergoing a first metatarsophalangeal (MTP) joint arthrodesis. To ensure optimal postoperative gait mechanics, what is the ideal position for the fusion?

. Neutral valgus and 0 degrees of dorsiflexion
. 5 to 10 degrees of varus and 5 degrees of dorsiflexion
. 10 to 15 degrees of valgus and 10 to 15 degrees of dorsiflexion relative to the floor
. 20 to 25 degrees of valgus and 30 degrees of dorsiflexion relative to the first metatarsal
. Neutral valgus and 25 degrees of plantarflexion

Correct Answer & Explanation

. 10 to 15 degrees of valgus and 10 to 15 degrees of dorsiflexion relative to the floor

Explanation

The gold standard treatment for end-stage hallux rigidus is 1st MTP arthrodesis. The ideal fusion position is 10-15 degrees of valgus and 10-15 degrees of dorsiflexion relative to the floor to allow for normal toe-off during the gait cycle.

Question 1146

Topic: 8. Foot and Ankle

A 48-year-old female with Coughlin and Shurnas Grade 2 hallux rigidus is scheduled for a dorsal cheilectomy. During the procedure, what is the maximum recommended percentage of the dorsal metatarsal head that should be resected to alleviate impingement while preventing joint instability?

. 10%
. 30%
. 50%
. 70%
. 90%

Correct Answer & Explanation

. 30%

Explanation

A dorsal cheilectomy involves removing the dorsal osteophytes along with a portion of the dorsal articular cartilage. Resection is typically limited to the dorsal 30% of the metatarsal head to preserve stability and avoid transferring weight to compromised cartilage.

Question 1147

Topic: 8. Foot and Ankle

Which of the following orthotic modifications is most appropriate for the non-operative management of symptomatic hallux rigidus?

. Flexible heel cup with a medial arch support
. Lateral wedge insole with a metatarsal pad
. Rigid Morton's extension with a stiff-soled shoe
. UCBL orthosis with a deep heel cup
. Metatarsal bar placed distal to the metatarsal heads

Correct Answer & Explanation

. Rigid Morton's extension with a stiff-soled shoe

Explanation

A rigid Morton's extension (a stiff plate extending under the first MTP joint) restricts motion at the first MTP joint, reducing pain during the toe-off phase of gait. It is highly effective for conservative management of hallux rigidus.

Question 1148

Topic: 8. Foot and Ankle

A 55-year-old male presents with dorsal midfoot pain and decreased great toe dorsiflexion. Radiographs reveal dorsal osteophytes with mild-to-moderate joint space narrowing (Coughlin and Shurnas Grade 2). He experiences pain at the extremes of range of motion but denies mid-arc pain. After failing shoe modifications, what is the most appropriate surgical intervention?

. First MTP arthrodesis
. Cheilectomy
. Keller resection arthroplasty
. First MTP total joint arthroplasty
. Weil osteotomy

Correct Answer & Explanation

. Cheilectomy

Explanation

Cheilectomy is the surgical treatment of choice for Grade 1 and 2 hallux rigidus with preserved mid-arc motion and pain exclusively at terminal dorsiflexion. It removes the dorsal osteophytes and the dorsal one-third of the metatarsal head to improve impingement.

Question 1149

Topic: Forefoot

A 70-year-old sedentary female undergoes a Keller resection arthroplasty for severe hallux rigidus. Postoperatively, she develops a "cock-up" deformity of the great toe and transfer metatarsalgia. The compromise of which structure during the index procedure most likely caused this complication?

. Extensor hallucis longus
. Flexor hallucis brevis
. Flexor hallucis longus
. Adductor hallucis
. Abductor hallucis

Correct Answer & Explanation

. Flexor hallucis brevis

Explanation

The Keller arthroplasty involves resecting the base of the proximal phalanx, which risks detaching the insertion of the flexor hallucis brevis. This loss of plantar intrinsic stability allows the extensor hallucis longus to overpower the digit, causing a cock-up deformity.

Question 1150

Topic: 8. Foot and Ankle

A 60-year-old male with Grade 4 hallux rigidus is undergoing a first metatarsophalangeal (MTP) joint arthrodesis. To optimize postoperative gait, shoe wear, and patient satisfaction, what is the ideal position for the fusion?

. 0-5 degrees of varus, 5-10 degrees of dorsiflexion, and slight supination
. 10-15 degrees of valgus, 10-15 degrees of dorsiflexion relative to the floor, and neutral rotation
. 10-15 degrees of valgus, 25-30 degrees of dorsiflexion relative to the floor, and neutral rotation
. 0-5 degrees of valgus, 15-20 degrees of plantarflexion, and neutral rotation
. 15-20 degrees of valgus, 0-5 degrees of dorsiflexion, and slight pronation

Correct Answer & Explanation

. 10-15 degrees of valgus, 10-15 degrees of dorsiflexion relative to the floor, and neutral rotation

Explanation

Optimal positioning for a 1st MTP arthrodesis is 10-15 degrees of valgus, 10-15 degrees of dorsiflexion relative to the floor (which equates to about 25-30 degrees relative to the first metatarsal), and neutral rotation.

Question 1151

Topic: 8. Foot and Ankle

A 45-year-old male runner complains of dorsal foot pain during toe-off. Examination reveals pain at the extremes of dorsiflexion of the first MTP joint. Radiographs show a dorsal osteophyte with mild joint space narrowing but preserved plantar joint space (Coughlin and Shurnas Grade 2). Conservative management has failed. Which procedure is most indicated?

. First MTP arthrodesis
. Keller resection arthroplasty
. First MTP joint cheilectomy
. First MTP total joint arthroplasty
. Proximal phalanx dorsiflexion osteotomy (Moberg)

Correct Answer & Explanation

. First MTP joint cheilectomy

Explanation

Cheilectomy, which involves excision of the dorsal osteophyte and dorsal one-third of the metatarsal head, is highly successful for Grade 1 and 2 hallux rigidus where the plantar cartilage remains viable. Arthrodesis is reserved for advanced stages (Grade 3 or 4) or failed cheilectomies.

Question 1152

Topic: 8. Foot and Ankle

When performing a first metatarsophalangeal (MTP) joint arthrodesis for severe Grade 4 hallux rigidus, what is the optimal position of the proximal phalanx to optimize postoperative gait?

. Neutral valgus, neutral dorsiflexion relative to the floor
. 10 to 15 degrees of valgus, 10 to 15 degrees of dorsiflexion relative to the floor
. 25 to 30 degrees of valgus, neutral dorsiflexion relative to the floor
. Neutral valgus, 30 degrees of dorsiflexion relative to the floor
. 5 degrees of varus, 10 degrees of plantarflexion relative to the floor

Correct Answer & Explanation

. 10 to 15 degrees of valgus, 10 to 15 degrees of dorsiflexion relative to the floor

Explanation

Optimal positioning for a 1st MTP arthrodesis is 10 to 15 degrees of valgus and 10 to 15 degrees of dorsiflexion relative to the floor (approximately 15-20 degrees of dorsiflexion relative to the first metatarsal). This specific alignment allows proper weight transfer during the toe-off phase of the gait cycle.

Question 1153

Topic: 8. Foot and Ankle

A Moberg osteotomy is occasionally used as an adjunct in the treatment of hallux rigidus. Which of the following best describes the biomechanical effect of this procedure?

. It shortens the first metatarsal to decompress the joint
. It shifts the articular cartilage dorsally on the metatarsal head
. It acts as a closing wedge dorsal osteotomy of the proximal phalanx to shift the arc of motion towards dorsiflexion
. It plantarflexes the first ray to increase the windlass effect
. It fuses the sesamoids to the metatarsal head

Correct Answer & Explanation

. It acts as a closing wedge dorsal osteotomy of the proximal phalanx to shift the arc of motion towards dorsiflexion

Explanation

The Moberg procedure is a dorsal closing wedge osteotomy of the base of the proximal phalanx. While it does not increase the total arc of motion of the MTP joint, it shifts the available motion into more dorsiflexion, thereby relieving pain during the terminal stance phase of gait.

Question 1154

Topic: 8. Foot and Ankle

A 65-year-old lady presents with bilateral hallux valgus. You obtain weight-bearing radiographs. Based on the provided AP radiograph of the right foot, which of the following findings is most consistent with the described deformity (intermetatarsal angle 15°, hallux valgus angle 35°, and minimal passive correction)?

. A. Normal sesamoid position with no subluxation.
. B. Medial sesamoid subluxation with lateral sesamoid in normal position.
. C. Significant lateral sesamoid subluxation, indicating pronation of the first metatarsal.
. D. Widening of the first metatarsophalangeal joint space.
. E. Absence of arthritic changes at the first metatarsophalangeal joint.

Correct Answer & Explanation

. C. Significant lateral sesamoid subluxation, indicating pronation of the first metatarsal.

Explanation

Correct Answer: CThe case describes a significant hallux valgus deformity with an intermetatarsal angle of 15° (normal < 9°) and a hallux valgus angle of 35° (normal < 15°). These severe angular deformities are typically associated with significant lateral subluxation of the sesamoid complex, which is a hallmark of first metatarsal pronation and hallux valgus progression. The AP radiograph (Figure 4.7) would visually confirm this lateral displacement of the sesamoids relative to the first metatarsal head.Option A (Normal sesamoid position)is incorrect because severe hallux valgus invariably involves sesamoid subluxation.Option B (Medial sesamoid subluxation)is incorrect; sesamoid subluxation in hallux valgus is typically lateral.Option D (Widening of the first metatarsophalangeal joint space)is generally not seen in hallux valgus; rather, joint space narrowing might indicate arthritic changes, or the joint space might appear normal or slightly compressed laterally.Option E (Absence of arthritic changes)is not guaranteed. While the case doesn't explicitly state arthritic changes on the right foot, a long-standing deformity of this magnitude often has some degree of degenerative change, and the question asks for the finding most consistent with thedescribed deformity, which is primarily angular and rotational, leading to sesamoid subluxation.

Question 1155

Topic: Forefoot

For the 65-year-old lady with an intermetatarsal angle of 15°, a hallux valgus angle of 35°, and minimal passive correction of the hallux on her right foot, assuming a normal first tarsometatarsal joint, what is the most appropriate surgical plan?

. A. Chevron osteotomy with a lateral release.
. B. Mitchell osteotomy with a medial capsular plication.
. C. Scarf osteotomy, lateral release, and potentially an Akin osteotomy.
. D. First metatarsophalangeal joint arthrodesis.
. E. Keller resection arthroplasty.

Correct Answer & Explanation

. C. Scarf osteotomy, lateral release, and potentially an Akin osteotomy.

Explanation

Correct Answer: CThe case explicitly states that for an intermetatarsal angle of 15° and a hallux valgus angle of 35° with minimal passive correction, the candidate would plan a scarf osteotomy combined with a lateral release and an Akin osteotomy of the proximal phalanx if necessary. This combination addresses the severe intermetatarsal angle, the significant hallux valgus angle, and the lack of passive correction. The Scarf osteotomy is chosen for its versatility and ability to achieve substantial correction without significant shortening, which is crucial for severe deformities.Option A (Chevron osteotomy)is typically reserved for mild to moderate deformities (IM angle < 13-15°, HV angle < 30-35°) and would likely be inadequate for the described severe deformity.Option B (Mitchell osteotomy)is also a distal osteotomy and, as mentioned in the case, produces shortening of the first metatarsal, which could lead to transfer metatarsalgia, making it less desirable for severe corrections.Option D (First metatarsophalangeal joint arthrodesis)is a salvage procedure or indicated for severe arthritis, recurrent deformity, or in specific cases like the patient's left foot with a missing second toe, but not as a primary procedure for a correctable deformity with a normal TMT joint.Option E (Keller resection arthroplasty)is generally reserved for elderly, low-demand patients with significant MTP joint arthritis and is associated with complications like hallux cock-up deformity and loss of push-off strength, making it less suitable for this active patient with a correctable deformity.

Question 1156

Topic: 8. Foot and Ankle

Following the decision to perform a Scarf osteotomy for the patient's right foot, the examiner asks why this procedure was chosen over simpler distal osteotomies. Which of the following is the most compelling reason for selecting a Scarf osteotomy in this specific case?

. A. It is a simpler procedure with a faster recovery time compared to distal osteotomies.
. B. It primarily addresses metatarsal shortening, which is the main issue in severe hallux valgus.
. C. Its versatility allows for greater correction of severe deformities and avoids metatarsal shortening.
. D. It provides less stable fixation, encouraging earlier mobilization.
. E. It is the only osteotomy that can be combined with an Akin osteotomy.

Correct Answer & Explanation

. C. Its versatility allows for greater correction of severe deformities and avoids metatarsal shortening.

Explanation

Correct Answer: CThe case explicitly states the advantages of a Scarf osteotomy: 'It is a very versatile procedure with stable fixation allowing postoperative mobilization without a cast. It maintains length of the metatarsal but allows translation, angulation and depression of the metatarsal head as necessary. It can also be used to shorten or even lengthen the metatarsal.' The candidate further explains that for the described degree of deformity (IM 15°, HV 35°) and lack of passive correction, a distal osteotomy would provide inadequate correction, and a Mitchell osteotomy specifically produces shortening, which could lead to transfer metatarsalgia. Therefore, the Scarf's versatility in achieving greater correction while maintaining metatarsal length is the key advantage.Option A (Simpler procedure with faster recovery)is incorrect. Scarf osteotomy is a more complex procedure than distal osteotomies, though it does allow early weightbearing due to stable fixation.Option B (Primarily addresses metatarsal shortening)is incorrect. Scarf osteotomymaintainsmetatarsal length and can even lengthen it, which is an advantage over procedures like Mitchell that cause shortening. Shortening is generally undesirable as it can lead to transfer metatarsalgia.Option D (Less stable fixation)is incorrect. The case states it provides 'stable fixation allowing postoperative mobilization without a cast.'Option E (Only osteotomy that can be combined with an Akin)is incorrect. An Akin osteotomy is a proximal phalangeal osteotomy and can be combined with various metatarsal osteotomies to address residual hallux valgus interphalangeus.

Question 1157

Topic: 8. Foot and Ankle

When discussing the proposed Scarf osteotomy with the patient, which of the following complications is specifically mentioned in the case as a potential risk that is difficult to treat?

. A. Superficial infection.
. B. Recurrence of the deformity.
. C. Significant stiffness of the MTP joint.
. D. Hallux varus.
. E. Intraoperative metatarsal fracture.

Correct Answer & Explanation

. D. Hallux varus.

Explanation

Correct Answer: DThe candidate explicitly states, 'I would mention the possibility of hallux varus as a complication as this is difficult to treat.' This directly answers the question.Option A (Superficial infection)is mentioned as a risk, but not specifically highlighted as 'difficult to treat' in the same context as hallux varus.Option B (Recurrence of the deformity)is mentioned as possible, especially in adolescent cases, but not described as 'difficult to treat' in the same way as hallux varus.Option C (Significant stiffness of the MTP joint)is mentioned as a possibility for a minority of patients, but again, not characterized as 'difficult to treat' in the same manner as hallux varus.Option E (Intraoperative metatarsal fracture)is mentioned as a possibility, but it's an acute intraoperative event, not a chronic post-operative complication described as 'difficult to treat' in the long term.

Question 1158

Topic: Forefoot

A few months post-Scarf osteotomy, the patient develops a flexible hallux varus deformity. Which of the following is the most appropriate initial management strategy for this complication, as discussed in the case?

. A. Immediate revision surgery with MTP joint arthrodesis.
. B. Transfer of a slip of the Extensor Hallucis Longus (EHL) tendon.
. C. Abductor hallucis and medial capsular release.
. D. Attempting improvement with normal footwear and observation.
. E. Resection of the medial eminence and lateral capsular plication.

Correct Answer & Explanation

. D. Attempting improvement with normal footwear and observation.

Explanation

Correct Answer: DThe case states, 'A subtle varus may improve as the patient returns to normal foot wear.' This indicates that for a flexible or subtle varus, initial non-operative management with observation and appropriate footwear is the first step. The case then describes soft tissue procedures (EHL slip transfer, abductor hallucis and medial capsular release) forflexibledeformity, and arthrodesis forsignificant stiffness or arthrosis. Since the question specifies a 'flexible' deformity, the initial approach would be the least invasive.Option A (Immediate revision surgery with MTP joint arthrodesis)is incorrect. Arthrodesis is reserved for significant stiffness or arthrosis, not for a flexible deformity, especially as an initial step.Option B (Transfer of a slip of the Extensor Hallucis Longus (EHL) tendon)andOption C (Abductor hallucis and medial capsular release)are soft tissue procedures described forflexibledeformity, but they would typically follow initial conservative measures if the varus does not resolve with footwear changes.Option E (Resection of the medial eminence and lateral capsular plication)is a procedure for hallux valgus, not hallux varus. Hallux varus involves the hallux deviating medially, so a lateral capsular plication would worsen it, and medial eminence resection is for the bunion deformity.

Question 1159

Topic: 8. Foot and Ankle
After successful treatment of the right foot, the patient's left foot, which previously underwent second toe removal and has recurrent hallux valgus symptoms, requires surgical intervention. Considering the oblique view of the left foot and the patient's history, what is the most appropriate surgical recommendation for the left hallux?
. Repeat Scarf osteotomy with lateral release and Akin osteotomy.
. Chevron osteotomy with a medial capsular plication.
. First metatarsophalangeal joint arthrodesis.
. Proximal phalangeal osteotomy (Akin) alone.
. Resection arthroplasty of the first MTP joint.

Correct Answer & Explanation

. First metatarsophalangeal joint arthrodesis.

Explanation

The absence of the second toe predisposes to recurrence, and arthrodesis of the hallux MTP joint is the preferred treatment. The absence of the second toe significantly alters the biomechanics of the forefoot, increasing the risk of recurrence with traditional hallux valgus correction procedures. Arthrodesis provides a stable, definitive correction in such complex cases.

Question 1160

Topic: 8. Foot and Ankle

During the physical examination for hallux valgus, the candidate outlines several key assessment points. Which of the following is NOT explicitly mentioned as a component of the physical examination in the case discussion?

. A. Assessment of gait and posture of the weighted foot.
. B. Palpation for areas of tenderness, including the hallux MTP joint and lesser metatarsal heads.
. C. Assessment of active and passive correction possible for the hallux.
. D. Assessment of ankle range of motion.
. E. Grind test to assess pain from loading the MTP joint.

Correct Answer & Explanation

. D. Assessment of ankle range of motion.

Explanation

Correct Answer: DThe candidate's description of the physical examination includes: 'I would examine the gait and the posture of the weighted foot... I would palpate for areas of tenderness, paying particular attention to the hallux MTP joint and lesser metatarsal heads. I would assess the degree of active and passive correction possible and the range of movement of the involved joints and look for gastrocnemius tightness. I would also perform a grind test to assess pain from loading the MTP joint. Neurovascular status must also be assessed.'While 'gastrocnemius tightness' is mentioned, which involves the ankle, a general 'assessment of ankle range of motion' beyond this specific test is not explicitly listed as a primary component of the hallux valgus examination in the provided text. The 'range of movement of the involved joints' refers specifically to the hallux MTP and first TMT joints.Options A, B, C, and Eare all explicitly mentioned in the candidate's detailed description of the physical examination.

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